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12/06/2005 17: 21 2094655773 SPECTRUM EXPLORATION PAGE 03 <br /> 5:49°.k1i Erlirn�mental d 2 51 [% <br /> UU 10 . 2371 P . 2k <br /> 17.,'22/2005 15:01 2094683433 EMD PAGE 03 I <br /> San Joaquin County ement <br /> Environmental <br /> ion S <br /> mental Health Department Unit IV Well Permit Applicatuppi <br /> JOB ADDRESS: C CYC S) 104 CA PERMIT SR#: <br /> 9--I <br /> ;I <br /> i LICENSED CONTRACTORS DECLARATION ( C9DD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of DIVISIOn <br /> 3 of the Business and Protea®ions Code and my license is in full force And effect. <br />�f License#, 5) ( Expiration Date: <br />! Date: Z 2 S mo <br /> Contractor: LU rt h i t 0 f�YL7w— AP x Via-% I ._ <br /> I it <br /> Signature: ` Title: 't7r-_ L r4 <br /> Prin name- -J�i� t�flt.dl <br /> I WORKERS' COMPENSATION DECLARATION <br /> I I hereby affirm under penalty of perjury one of the following declara�fions: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the workfor which this permit is Issued. <br /> I have and will maintain workers'compensetlon insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued,`My workers compensation insurance <br /> carrier amend` ,pooli`cy numbers are: —} <br /> Cartier; c7�11�C. Vim( Poffcy Number: I� T 000 SS" O"1 <br /> f _I certify that in the performance or the work for which this permit is Issued, 1 shall not employ any person in <br /> j any manner so as to become subject to the workers'compensgdon laws of California, and agree that If 1 <br /> should become subject to the workers'compens n provisions Of Section 3700 of the Labor Code, I shall, <br /> forthwith comply with those provisions. <br /> Date: L Z I Z I D S 5ignalure: <br /> Printed Name: Jean r1C h <br /> i. <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, (signature 6fC•57 licensed authorized representative), <br /> hereby autharife(print name) LTV,AIG(I�I <br /> to oion this Sen Joaquin County Well Permit Applleallon on my behalf. I understand this authorization is valid for <br /> One (1)year and Is.limited to the work plan dated on the front pago of this oppllcatton. <br /> 1.25-021 MI <br />